Left Atrial Appendage Occlusion Versus Anticoagulation in Atrial Fibrillation: Equipoise When Bleeding Risk Is High
Authors: Bharat K. Kantharia
Journal: Annals of Internal Medicine (2022)

EditorialsSeptember 2022Left Atrial Appendage Occlusion Versus Anticoagulation in Atrial Fibrillation: Equipoise When Bleeding Risk Is HighBharat K. Kantharia, MDBharat K. Kantharia, MDCardiovascular and Heart Rhythm Consultants and Icahn School of Medicine at Mount Sinai, New York, New YorkSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/M22-2271 SectionsAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Atrial fibrillation (AF) affects millions of people and, with associated increased risk for mortality and morbidity, including stroke, poses many perplexing clinical challenges (1, 2). Over the past 2 decades, there has been significant progress in our understanding of AF and its management (3). Stroke prevention is a major emphasis of AF management. Oral anticoagulants (OACs) clearly reduce the risk for stroke in patients with AF and concomitant risk factors (4). Because the left atrial appendage (LAA) is a major site of formation of thrombi, methods to exclude the LAA from circulation, either surgically or by occlusive devices (LAA occlusion ...References1. January CT, Wann LS, Calkins H, et al. 2019 AHA/ACC/HRS focused update of the 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol. 2019;74:104-132. [PMID: 30703431] doi:10.1016/j.jacc.2019.01.011 CrossrefMedlineGoogle Scholar2. Hindricks G, Potpara T, Dagres N, et al; ESC Scientific Document Group. 2020 ESC guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS): the Task Force for the Diagnosis and Management of Atrial Fibrillation of the European Society of Cardiology (ESC) developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC. Eur Heart J. 2021;42:373-498. [PMID: 32860505] doi:10.1093/eurheartj/ehaa612 CrossrefMedlineGoogle Scholar3. Lévy S, Steinbeck G, Santini L, et al. Management of atrial fibrillation: two decades of progress — a scientific statement from the European Cardiac Arrhythmia Society. J Interv Card Electrophysiol. 2022. [PMID: 35419669] doi:10.1007/s10840-022-01195-z CrossrefMedlineGoogle Scholar4. Hart RG, Benavente O, McBride R, et al. Antithrombotic therapy to prevent stroke in patients with atrial fibrillation: a meta-analysis. Ann Intern Med. 1999;131:492-501. [PMID: 10507957] LinkGoogle Scholar5. Reddy VY, Sievert H, Halperin J, et al; PROTECT AF Steering Committee and Investigators. Percutaneous left atrial appendage closure vs warfarin for atrial fibrillation: a randomized clinical trial. JAMA. 2014;312:1988-98. [PMID: 25399274] doi:10.1001/jama.2014.15192 CrossrefMedlineGoogle Scholar6. Holmes DR Jr, Kar S, Price MJ, et al. Prospective randomized evaluation of the Watchman left atrial appendage closure device in patients with atrial fibrillation versus long-term warfarin therapy: the PREVAIL trial. J Am Coll Cardiol. 2014;64:1-12. [PMID: 24998121] doi:10.1016/j.jacc.2014.04.029 CrossrefMedlineGoogle Scholar7. Holmes DR Jr, Doshi SK, Kar S, et al. Left atrial appendage closure as an alternative to warfarin for stroke prevention in atrial fibrillation: a patient-level meta-analysis. J Am Coll Cardiol. 2015;65:2614-2623. [PMID: 26088300] doi:10.1016/j.jacc.2015.04.025 CrossrefMedlineGoogle Scholar8. Mascarenhas DAN, Sharma M, Ziegler PD, et al. Role of cardiovascular implantable electronic devices in delivering individualized disease-guided management of patients with non-valvular atrial fibrillation and high bleeding risk. Acta Cardiol. 2019;74:131-139. [PMID: 29863432] doi:10.1080/00015385.2018.1475029 CrossrefMedlineGoogle Scholar9. Chew DS, Zhou K, Pokorney SD, et al. Left atrial appendage occlusion versus oral anticoagulation in atrial fibrillation. A decision analysis. Ann Intern Med. 2022;175:1230-1239. doi:10.7326/M21-4653 LinkGoogle Scholar10. Osmancik P, Herman D, Neuzil P, et al; PRAGUE-17 Trial Investigators. 4-year outcomes after left atrial appendage closure versus nonwarfarin oral anticoagulation for atrial fibrillation. J Am Coll Cardiol. 2022;79:1-14. [PMID: 34748929] doi:10.1016/j.jacc.2021.10.023 CrossrefMedlineGoogle Scholar Author, Article, and Disclosure InformationAuthors: Bharat K. Kantharia, MDAffiliations: Cardiovascular and Heart Rhythm Consultants and Icahn School of Medicine at Mount Sinai, New York, New YorkDisclosures: The author has reported no disclosures of interest. The form can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M22-2271.Corresponding Author: Bharat K. Kantharia, MD, Cardiovascular and Heart Rhythm Consultants, 30 West 60th Street, Suite 1U, New York, NY 10023; e-mail, bharat.[email protected]org.This article was published at Annals.org on 16 August 2022. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoLeft Atrial Appendage Occlusion Versus Oral Anticoagulation in Atrial Fibrillation Derek S. Chew , Ke Zhou , Sean D. Pokorney , David B. Matchar , Sreekanth Vemulapalli , Larry A. Allen , Kevin P. Jackson , Zainab Samad , Manesh R. Patel , James V. Freeman , and Jonathan P. Piccini Metrics September 2022Volume 175, Issue 9Page: 1330-1331KeywordsAtrial fibrillationCardiology and cardiovascular diseasesStroke ePublished: 16 August 2022 Issue Published: September 2022 Copyright & PermissionsCopyright © 2022 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...